Supporting the Families of Adults Experiencing Gender Discomfort and Transsexualism.
The Gender Identity Research and Education (GIRES) provides information and education to families in which an adult member experiences gender discomfort or transsexualism. So far, it has directly helped 160 people by means of individual advice sessions and telephone contact, and, in collaboration with Mermaids and Depend, workshops that enable families to meet others with relevant experience. GIRES believes that the information below would be helpful to other families dealing with these issues and to the organisations that wish to support them.
GENDER IDENTITY AND TRANSSEXUALISM
Family members faced with issues of gender dysphoria and transsexualism usually seek an answer to the same burning questions: how has this occurred? what did I do wrong? The following information should help them by explaining what is understood about the development of gender dysphoria, and relieving them of any sense of being guilty for the way it has developed.
Male and female characteristics depend on two factors: sex and gender. 'Sex' describes our physical structure, including external appearance, internal organs and brain, which all differ between males and females. There are two different aspects to gender: 'gender identity' describes the inner sense of knowing that we are boys or girls, and later men or women; 'gender role' describes how we behave in society. Even though we now live in a more equal society, boys and girls are still expected to dress differently from each other and, possibly, enjoy different kinds of games. Each is expected to have rather different interests and different groups of friends.
Typically, sex, gender identity and gender role are consistent with each other. So, we tend to think of human beings as falling into two distinct categories: boys and men, who are 'male'; girls and women who are 'female'. As soon as the sex of a baby is apparent, it is assumed that the gender identity matches. However, people vary greatly and it should not be surprising that, occasionally, a few individuals experience a mismatch. The way they look on the outside doesn't fit how they feel inside. The way they are expected to behave may be quite different from the way they actually want to behave. This causes a feeling of intense discomfort which is described as 'gender dysphoria' (dysphoria means unhappiness). This condition is increasingly understood to have its origins before birth. Research studies indicate that a small part of the baby's brain develops in opposition to the sex of the rest of its body. This predisposes the baby to a future mismatch between gender identity and sex.
As the individual grows through childhood, adolescence and on into adulthood, the discomfort may become extreme. Even so, many will continue to strive to live and behave according to the gender role that society expects of them. However, for some, the stress of their situation may become so intolerable that medical help is sought to enable the individual concerned to undergo 'transition', that is, to live according to the opposite gender role, and to have treatment, usually including hormone medication and surgery, to bring the body more closely in line with the underlying gender identity. Those who seek this treatment may be referred to as transsexual people or trans men (female to male) and trans women (male to female). This treatment is very successful in giving trans people the feeling of harmony that they seek.
Gender dysphoria has nothing to do with sexuality, that is, whether a person is gay/lesbian or straight. The sexual orientation of trans people, as in the population generally, may be towards men, women or both, or they may have no sexual interest at all. In any case, the trans person is likely to be unsure of future orientation until gender confirming surgery has been completed. It may remain the same; it may change.
Gender dysphoria is not a mental illness, although the condition can cause great stress in the lives of the individuals concerned and their families.
Trans people's rights are now recognised in law. They will be able to obtain a Gender Recognition Certificate, leading to new birth certificate, which will help to prevent discrimination against them. They will also be allowed to marry in their newly recognised gender.
However, as a consequence of society's lack understanding and care, trans people often suffer a great deal, just at a time when they most need support. Many find that their families reject them. Sometimes, despite being protected by employment law, they are made to feel very uncomfortable at work, as well as elsewhere. It takes great courage for trans people to reveal their true gender identities. They deserve respect and understanding.
FAMILIES' NEED FOR SUPPORT
Families' support for gender dysphoric and transsexual people is vital. Poor support has been shown to make it more likely that trans people will regret their transition to a new gender role, post surgery.
However, families themselves also need support if they are to be able to help their trans loved one. Families' own needs are often neglected by the gender identity clinics that treat trans people, even deliberately. Family members are subjected to extreme stress, especially partners. Typical reactions to the news of a loved one's gender dysphoria, especially if it has already been confirmed as transsexualism, include:
- pain and grief
- losing control
- embarrassment and shame
- fear, for self and loved one
- possibly religious concerns
In cases where the transition occurs late in the trans person's life, it often involves partners/spouses and children, which greatly aggravates relationship difficulties. The partner/spouse may feel betrayed, especially if told late in the decision-making process. If the trans person has children, the partner/spouse will be deeply concerned about the effect on them. The partner/spouse may be deeply concerned about being labelled lesbian or gay and, perhaps, having to face the problems of a sexually unfulfilling relationship.
Nonetheless, for some families, there may also be relief that a mystery has been solved. They may, for many years, have wondered and worried about some inexplicable ways in which their loved one has behaved.
Almost invariably, families will not know the best way to respond. Their initial shock and resistance to the idea of transsexualism are understandable reactions. They do need to be convinced that this is the right path for the person they love. However, the search for easy solutions is usually fruitless. It is unlikely, and perhaps unsafe, for an adult trans person to change his or her mind and revert to the initial gender role and presentation. Trying to persuade the trans person to delay transition may be very harmful. Very probably, the trans person has already reached crisis point before telling the family. Once the trans person begins to tell people about the intention to begin transition, it is impossible to keep it a secret.
In their anxiety, families often fail to recognise that the trans person and his or her love for other members of the family remain unchanged. The trans person will be acutely aware of the pain that this situation causes other family members and feeling deep sorrow about that. However, family members need to be aware that the trans person is driven by an overwhelming need to live in accordance with his/her innate gender identity, while remaining reliant on the family's acceptance, listening, understanding, advice, support and, above all, love.
Nonetheless, it is true that trans individuals may become entirely self-focused through the transition process. Society often places major obstacles in their way and overcoming them requires determination. They may feel that have spent their entire lives pleasing everyone else; now it's their turn. They will want their families to be happy for them. Sometimes, they will have difficulty in understanding why their families are not enthusiastic about this transformation.
ISSUES TO BE FACED
It is helpful for trans people and their families to look realistically at the daunting range of issues to be dealt with during the transition process as listed below. Many of these issues are dealt with in detail elsewhere on this website.
- Psychiatric assessment to confirm the diagnosis
- Understanding a vast amount of new information about gender identity and transsexualism
- Obtaining funds for treatment, NHS or private
- Carefully informing all who need to know
- Undergoing the real life experience that is a mandatory precursor to surgical treatment, which requires living in the new gender role full-time
- Handling relationships
- Maintaining access to own children
- Certificate of gender confirmation treatment for use if challenged in using toilets or other gender-segregated facilities
- Statutory declaration of new identity to use in obtaining new documents
- Pension provisions
- Entitlement to state benefits
- Entertainment and social activities
- Media intrusion
- Transphobic crime
- Legal support to deal with extreme problems
- Crisis, even rape, support
- Artificial body parts
- Clothing, footwear and wigs
- Behaviour and deportment
- Hair removal
- Speech therapy
- Surgery, for trans men (assigned as female at birth) or trans women
- Driving licence
- Degrees and other qualifications
- GP and other doctors
- Other medical services e.g. Dentist, Optician
- Tax and National Insurance
- Personnel records at work
- Pension records
- Benefits Agency
- Job Centre
- Bank and Building Society
- Personal and household insurance policies
- H.P. Agreements
- Credit cards
- Utilities: Gas, Electricity, Water, Phone
- Council Tax
- Electoral Roll
- Club memberships
- Birth certificate, after grant of a gender recognition certificate, (commencing 2005)
- ID Cards (commencing whenever the proposed new legislation comes into effect)
In this complex and changing situation, the inevitable stress, for trans people and their families, severely inhibits communication, making it even harder for all of them to sustain an effective relationship.
Very often, the importance of surgery is given exaggerated importance, by trans people and their families, in comparison with the many other factors above that have to be dealt with successfully to ensure a happy life for the trans person. However, for most trans people, surgery is essential and it is very expensive. Many trans people cannot afford private treatment. The NHS makes only limited funds available for this treatment. Funding priorities are set locally by the strategic health authorities and primary care trusts. Waiting lists for surgery, or indeed for other medical treatment can be long.
Families, as well as trans people, need to be aware of the main surgical options:
a - MtF (Trans Woman):
- orchidectomy - removal of testicles
- penectomy - removal of penis
- vaginaplasty - creation of vagina
- clitoroplasty - creation of clitoris
- mammoplasty - breast enlargement
- tracheal shave - reduction of Adam's apple
- facial feminising - especially reshaping the nose and chin
b - FtM (Trans Man):
- mastectomy - removal of breasts
- hysterectomy - removal of uterus
- oopherectomy - removal of ovaries
- metoidioplasty - creation of micro-penis, using the clitoris
- phalloplasty - creation of penis, with or without urethra
- penile implant - making erection possible
Hormone treatment is likely to affect the trans person's libido (sex-drive). In trans women (MtF), the effect of the hormones (anti-androgens and estrogens) is likely to reduce libido. In trans men (FtM), it is likely to be increased by the hormones (testosterone). Both trans women and trans men can experience orgasm post-operatively.
HOW TO SUPPORT FAMILIES
The support that best helps families includes:
- Providing information on gender dysphoria and transsexualism.
- Promoting mutual insight, so that:
- family members understand the trans person's reality.
- the trans person understands the family's bewilderment and sense of loss.
- Providing opportunities to share feelings with others in similar position.
- Encouraging realism and optimism.
GIRES can provide a literature pack that deals with:
- a full scientific explanation of gender dysphoria and transsexualism
- the support groups that can help trans people and family members (these are voluntary organisations with relevant expertise; confidentiality is assured for those who contact them; GIRES can provide a list of these organisations, which gives information on the services they offer and how to contact them.)
Families often seek guidance about the best way to respond. The advice that seems most valuable to them is:
- Don't ignore the problem and hope that it will go away.
- Welcome discussion with your family member whenever he or she wishes to talk about gender identity issues.
- Allow yourself to become convinced as rapidly as you can that you should and will unconditionally accept your loved one's decision about his or her gender identity and give them your support; do this in days, ideally, in weeks if possible, rather than months.
It will then be best for you and for your loved one if you:
- respect the fundamental right of your family member to be true to him or herself.
- accept that living in accordance with the core gender identity is now absolutely essential for him or her.
- are realistic rather than pessimistic about the many problems that you both will have to face.
- take positive action so that you influence events rather than allow them to drive you.
- resist the notion that you are to blame or in any way responsible for your loved one's decision.
- share the news with at least one other person whom you can rely on to respect the need for confidentiality, until you and your family member are ready to share it more widely.
- contact a support group.
- if you still find the stress too much to handle, obtain professional help, perhaps via your GP.
- provide a safe haven where your loved one will feel protected from an often hostile outside world.
- use the name and also the pronouns that your loved one prefers: "she", "he", "her", "him", "hers", "his"; both of you must expect that you will, initially, often get this wrong.
- offer advice tactfully, e.g. on clothes, make-up, etc.
- learn about gender identity development from literature, articles, books and, if you can, internet sites set up by reputable organisations.
- learn the language used in your loved one's new world: e.g. "sex", "gender identity", "gender role", "male", "female", "masculine", "feminine", "gender dysphoria", "transsexualism", "transition", "trans man", "trans woman".
- appreciate that your loved one is having to explore a new world of trans people and those that serve their special needs.
- gradually inform others who need to know, especially family members.
- become confident and knowledgeable enough to challenge ignorance and intolerance in others.
- look for ways to help others in a similar position.
What will be unhelpful is to:
- continue refusing to believe what your loved one is telling you.
- try to make things like they previously were.
- keep the news a complete secret from everyone.
- become antagonistic towards the professionals who are trying to help your loved one.
- allow yourself to believe that there is nothing positive you can do.
- expect only bad consequences from your loved one's decision to have treatment for his or her gender dysphoria.
HELP FOR THE TRANS PERSON'S CHILDREN
Major issues often arise concerning the children of a trans person. Parents may wish for help in informing their children about gender identity and transsexual issues. For this purpose, GIRES can provide explanations, set at two levels: one for pre-teens, the other for teenagers. These documents are also useful for schools that have to deal with such issues, because either pupils have trans parents or pupils are themselves gender dysphoric. In some cases, parents may separate, with one of them having custody of the children. The parent having custody may deny the other parent reasonable access to the children. In such a case, a court hearing may ensue. GIRES provides literature to help the trans parent in such circumstances.
Note that children themselves may experience uncertainty or confusion about their gender identities from as young as three of four years old. Helping them is not the subject of this paper which is intended to help the families of adults. Families seeking help with the gender identity development of their children should contact Mermaids which is support group for children and teenagers coping with gender identity issues and their families. This charity provides a telephone helpline (07020 935066), e-mail contact (email@example.com) and website (http://www.mermaids.freeuk.com).
WORKSHOPS FOR FAMILIES
The workshops that GIRES has run, in 9 major cities throughout the UK, allowed participants to share their experiences and put questions to the trans people and family members that made up the team of presenters. Each workshop, lasting three hours, took place on Saturday afternoons when it was reasonably certain that the trans people and their families would be free to attend. Participants included partners, children, parents, siblings, friends and also trans people, but only if they attended with their families. Allowing trans people to attend without their family members would have focused discussion on the problems that trans people face, at the expense of spending time on the vital issue of family relationships. Although a number of counsellors and others asked to attend the workshops, no spectators were allowed in order to ensure that participants felt free to talk openly to people directly sharing similar experiences.
The ground rules that GIRES set creates a safe and supportive atmosphere. Everyone should be treated with respect. Confidentiality should be assured. Assurances should be given that no information will be passed on to those providing treatment. Family members should be warned not to attempt to interfere in treatment.
For part of the time, participants are divided into three smaller groups: trans people, partners, parents and siblings. Each group is facilitated by an appropriate team member. This enables participants to concentrate on issues specific to their personal situation, and it greatly facilitates discussion in a safe environment.
The evaluation forms completed by participants showed that they had been helped to understand and accept their loved one's condition. Their comments also showed that they had obtained reassurance through:
- knowing "I'm not the only one"
- companionship and sharing
- ability to talk openly
- hugs with other participants
Another important benefit of bringing families together is that it enables them, by exchanging telephone numbers and e-mail, to network after the workshop is over.
In presenting the workshops, GIRES collaborated with two other organisations that provide support for families nationally. One of these is Mermaids (see above). The other organisation is Depend, a group supporting the families and friends of transsexual people via email (firstname.lastname@example.org) and a website (http://www.depend.org.uk). GIRES can also provide information about the local groups that support families in several areas of the UK.
GIRES is willing to run further workshops wherever another organisation, such as a gender identity clinic, can assemble a group of family members.
LOCAL SUPPORT GROUPS
Local support groups for families have been set up in Southampton, Telford, Newcastle and Glasgow. Clearly, this provides incomplete coverage of the UK and many more groups are needed. GIRES strongly encourages other organisations to establish groups and can provide small amounts of funding to help them get started. However, experience shows that it is quite difficult to get the word out to families about the existence of the group, persuade them that it would be appropriate for them to attend and attract an adequate level of participation. Anyone attempting to start a group would have to put a lot of effort into publicising it. It can be promoted by contacting trans people themselves via the self-help groups, gender identity clinics, doctors and therapists that support them. However, the trans person may not pass on the invitation to the members of his or her family because they have not yet been told about the gender identity issues or because they have been told but, as happens far too often, have already rejected the trans person. So, the sponsors of support groups need to seek additional ways to get their message to the families, for instance via GPs' surgeries, therapists and counsellors, Samaritans, CABs and even advertising.
ROLE OF THE GENDER IDENTITY CLINICS
GIRES urges all Gender Identity Clinics to provide support for families. Based on the comments of participants in the workshops, this should include:
- helping the gender dysphoric person to consider how best to preserve family relationships
- talking with the family, rather than being remote
- with the consent of the gender dysphoric person, permitting other family members to attend at least one meeting with the supervising clinician
- providing advice and information for family members
- organising opportunities to meet other families in the same situation
- providing information on other sources of information and support
- not allowing the family to influence treatment decisions or using it merely to check on what the gender dysphoric person has said
- visiting the trans person's workplace to explain gender dysphoria and transsexualism, thereby preventing the discrimination that too often ruins the lives of transsexual employees
GIRES will provide information and literature about gender dysphoria and transsexualism, their effects on family relationships, effective ways to support families and where to obtain other help. Contact details for the charity are available here.
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